Enterogastric Reflux Research Articles

Endoscopic mucosal phenotypes and endoscopic Sydney system gastritis assessment in relation to Helicobacter pylori infection and upper digestive clinical signs: A 2‐year study among patients with gastroduodenal disorders in Cameroon

AbstractBackground and AimHelicobacter pylori represents the major pathogen in the pathophysiology of diverse gastrointestinal conditions. This study sought to determine the endoscopic aspect of the gastric mucosa in relation to H. pylori infection in Cameroon.MethodsThis study was conducted in three reference health facilities in Cameroon from October 2020 to October 2022. The study enrolled 494 consecutive volunteer dyspeptic patients attending to the gastroenterology department of the selected health facilities. A description of the aspect of gastric mucosa of all participants was performed during endoscopy examination, and biopsies were collected for H. pylori detection using rapid urease tests.ResultsGastritis, ulcerated lesions, duodenitis, esophagitis, normal mucosa aspect, bulbitis, and gastric neoplastic lesions were found in 40.1, 22.3, 10.9, 10.3, 9.7, 6.3, and 0.40% of biopsy samples, respectively. Erythematous/exudative (45.9%) and enterogastric reflux (12.2%) were the main gastritis types recorded. H. pylori was present in 58.1, 46.3, 87.1, 66.7, and 61.8% in gastritis, duodenitis, bulbitis, esophagitis, and ulcerated lesions, respectively. A positive relationship was noticed between the presence of H. pylori and gastritis (1.037 [0.720–1.493]; P = 0.845), bulbitis (4.237 [1.602–11.235]; P = 0.004), esophagitis (1.515 [0.822–2.793]; P = 0.183), ulcerated lesions (1.233 [0.798–1.904]; P = 0.345), erythematous/exudative gastritis (1.354 [0.768–2.389]; P = 0.295), and enterogastric reflux gastritis (1.159 [0.492–2.733]; P = 0.736).ConclusionGastritis and erythematous/exudative gastritis are the most frequent gastrointestinal pathophysiology conditions in dyspeptic patient in our milieu. H. pylori infection is responsible for 94.8% of the gastrointestinal pathophysiology conditions with bulbitis as the condition is significantly associated with this bacterium infection.

Gallbladder agenesis and enterogastric reflux in an adult patient diagnosed by Tc99m HIDA SPECT-CT scintigraphy: a case report

Background: Gallbladder agenesis is an extremely rare, usually asymptomatic anatomic variation. Enterogastric reflux (EGR) in a patient with gallbladder agenesis was not reported previously. We report a rare case of EGR in a patient with gallbladder agenesis, diagnosed on 99mTc HIDA (hepatobilliary iminodiacetic acid) SPECT-CT (single-photon emission computed tomography-computed tomography) scintigraphy. Case Presentation: A 35-year-old female was referred to Nuclear Medicine Department for Tc99m HIDA scan. She had history of surgical exploration to remove the gallbladder due to suspicion of chronic cholecystitis. But intraoperatively gallbladder was not localized and the patient was referred for Tc99m HIDA scan. Tc99m HIDA scan along with SPECT-CT showed reflux of tracer into the stomach and non-visualized gallbladder. Further imaging by magnetic resonance cholangiopancreatography confirmed the diagnosis of congenital absence of the gallbladder. Conclusion: We conclude that 99mTc HIDA SPECT-CT scintigraphy is helpful in evaluating the true etiology of biliary colic. It should be cautiously reported, mentioning the EGR if present as it may be the true etiology of biliary colic in patients with and without gall bladder. It prevents the added morbidity of surgery, performed with the suspicion of cholecystitis.

Prospective randomised study comparing Billroth II with Braun anastomosis versus Roux-en-Y reconstruction after radical distal gastrectomy for gastric cancer

Background: Enterogastric reflux of bile is a major cause of morbidity following distal gastrectomy. Various reconstructive methods were developed to overcome this.Methods: A prospective randomised study included all patients undergoing distal gastrectomy for gastric cancer was conducted during the period June 2012 and November 2016. After resection, they were randomized to undergo Billroth II with Braun anastomosis (BEE) (n = 28) or Roux-en-Y (RY) gastrojejunostomy (n = 26). Endoscopy and biliary scintigraphy were done at 3 months to assess the severity of gastritis and the presence of bile reflux in remnant stomach. Stomach was biopsied for histopathology. Quality of life (QOL) was assessed using gastric cancer-specific questionnaire.Results: Demographics and nutritional status was similar. Intraoperative variables, post-operative recovery and hospital stay were not statistically different. Remnant stomach in BEE group showed more severe and extensive gastritis than RY group. The incidence of bile reflux on endoscopy was statistically significantly high in BEE (P < 0.0001). The histological findings of endoscopic biopsies were similar. The incidence of bile reflux on scintigraphy was lower in RY group (10.7% vs. 46.2%; P = 0.03). The QOL symptom score was similar.Conclusions: The incidence of bile reflux and severity of gastritis is less in patients who underwent RY gastrojejunostomy when compared to Billroth II with Braun anastomosis without any significant difference in QOL.

Encarcelamiento intestinal en forame epiplóico: Relato de caso en equino

The epiplastic foramen is a natural opening in the thoracic cavity that communicates with the abdominal cavity, located dorsally to the cleft of the liver, contacting the caudal vena cava, portal vein, pancreas, hepatoduodenal ligament and with the small intestine loops. Horses diagnosed with intestinal loop incarceration in the epiplastic foramen require surgical treatment, with a prognosis of being reserved to unfavorable, and the ileum is the intestinal segment most affected in this disease. In addition, because of a strangulative process, the animal shows signs of abdominal discomfort called colic and enterogastric reflux, but clinical signs are variable. Some animals in the palpation present palpable small intestine or not and abdominal discomfort varying from mild to severe. The objective of this work is to report a case of a 5-year-old female Quarter Horse, weighing 430 kg, with a history of abdominal discomfort two days ago and with intermittent pains, from the municipality of Batatais, Veterinary Hospital of Batatais, addressing the animal clinic, diagnosis and treatment. In the rectal palpation he identified slightly distended loops and palpable small intestine and puncture of the peritoneal fluid through the abdominocentesis showed a reddish coloration. The animal was under observation, but even with all the clinical interventions, the pain picture increased and with that it was submitted to exploratory laparotomy, where the incarceration was diagnosed in the epiplastic foramen. In view of the clinical case, it was concluded that the incarceration of the epiplastic foramen may lead to significant intestinal loops involvement, progressing to destabilization of the general state of the animal, being aggravating factors for the surgical procedure, becoming a case of risk of the patient. The animal in this report was submitted to euthanasia due to the great compromise of the intestinal loops. It is concluded that the diagnosis should be performed as early as possible, increasing the chance of resolution with favorable prognosis.

Enterogastric Reflux: An Uncommon Diagnosis Analyzed by Hepatobiliary Imaging

Enterogastric reflux (EGR) is the reflux of bile and digestive enzymes from the small bowel into the stomach. While it is a normal physiologic process in small amounts, excessive reflux and chronic EGR can cause upper GI symptoms often mimicking more common diseases such as gallbladder disease and GERD that often leads to its underdiagnosis. Identifying EGR is significant as it has been associated with the development of gastroesophogeal pathology including gastritis, esophagitis, ulcers, and mucosal metaplasia. This article presents a 22-year-old male with enterogastric reflux causing upper abdominal pain and will discuss the role of hepatobiliary scintigraphy in its diagnosis.

Enterogastric Reflux: an Uncommon Diagnosis Analyzed by Hepatobiliary Imaging

Enterogastric reflux (EGR) is the reflux of bile and digestive enzymes from the small bowel into the stomach. While it is a normal physiologic process in small amounts, excessive reflux and chronic EGR can cause upper GI symptoms often mimicking more common diseases such as gallbladder disease and GERD that often leads to its underdiagnosis. Identifying EGR is significant as it has been associated with the development of gastroesophogeal pathology including gastritis, esophagitis, ulcers, and mucosal metaplasia. This article presents a 22-year-old male with enterogastric reflux causing upper abdominal pain and will discuss the role of hepatobiliary scintigraphy in its diagnosis.

Ileal Bypass Followed by Tiflostomy to Treat Acute Abdomen in a Horse

Background: Equine gastrointestinal colic cases represent one of the diseases with higher morbidity and mortality. Short and long term survivals are commonly correlated with the colic causes, being considered 50% the survival rate of horses referred to surgery because of small intestine strangulative causes. The jejuno-caecostomy technique is recommended in cases of ileum necrosis or ischemia that indicates ileum removal. The survival rate after this procedure is low, being even lower than others common terminal-terminal enteroanastomoses. This study reports a case of jejuno-caecostomy followed by tiflopexy and tiflostomy performed in a colic horse.Case: A 12-year-old mare, mangalarga breed, with a history of acute abdomen during 18 h was referred to the FZEA-USP equine hospital. According to the owner, the animal suffered previous episodes of colic that had been solved without treatment. On this occasion, the owner, without veterinary advice, had administered 10 mL of flunixin meglumine, but the animal did not show improvement. During the examination, the patient presented tachycardia, tachypnea, toxemic mucosa, a large amount of enterogastric reflux, and it was possible to observe distended small intestine during rectal palpation. The horse was referred to surgery; it was possible to identify necrosis of the ileum and 30 cm of the aboral segment of the jejunum, caused by strangulation due to a pedunculated lipoma localized in the medial band of the caecum. Latero-lateral jejuno-caecostomy was performed between the medial and dorsal bands of the caecum, using polyglactin 910, nº 2.0, potassium penicillin 30.000 IU / kg, every 6 h, gentamicin 6.6 mg / kg, every 24 h, flunixin meglumine 1.1 mg / kg, every 12 h and maintenance fluid therapy were performed post operatively. The animal had ileus and severe enterogastric reflux for five days postoperatively, showing severe signs of endotoxemia, and parenteral hydration seemed to be not enough. So it was decided to hydrate the animal through the caecum. It was performed a tiflostomy and the implantation of a Foley catheter, nº 24, followed by tiflopexy. During this procedure, it was possible to diagnostic, via intra-abdominal palpation, a significant type I cecal impaction. Immediately after the procedure, the animal presented no more enterogastric reflux and started to defecate pasty manure. Two days after the procedure, the animal died. During necropsy, the anastomoses region showed a great healing process, without folds or stenosis and the functional test of the region was performed, showing no leakage, ensuring the success of the anastomosis technique; the tiflopexy was adequate, and the other intestinal segments presented normal.Discussion: In this report it was possible to observe several postoperative complications such as enterogastric reflux, type I caecum impaction, ileus, and endotoxemia, which was determinant for the death of the animal. Probably the cecal impaction was responsible for the enterogastric reflux and ileus, contributing with the endotoxemia and hydro electrolytic imbalance. These facts evidenced the necessity of faster and more efficient actions in future cases with similar complications, such as the accomplishment of a tiflostomy more precociously avoiding the impaction of caecum and minimizing the electrolytic imbalances of the patients. It was concluded that the delay in the patient referral, followed by the advanced hydro electrolytic imbalance and endotoxemia were the main factors responsible for the treatment failure.

Functional Condition of the Stomach and The Small Bowel after pancreatic resection

Актуальность. На сегодняшний день отсутствует единый подход в выборе наиболее физиологичного способа рекон-структивного этапа операций. Основными методами исследования моторики желудка и тонкой кишки на сегодняшнийдень являются следующие – рентгенологическое исследование желудочно-кишечного тракта с бариевой взвесью, дыха-тельные тесты, а также беспроводные электронные системы.Цель исследования. Определение наиболее физиологичных способов формирования анастомозов при выполнении ради-кального оперативного вмешательства у больных с опухолевым поражением головки поджелудочной железы на основа-нии оценки функционального состояния желудка и тонкой кишки.Материалы и методы. В условиях специализированного отделения хирургии печени и поджелудочной железы ГКБ имС.П. Боткина и отделения методов радионуклеидной диагностики ГКБ №1 им. Н.И. Пирогова проведено проспективноеклиническое исследование функционального состояния желудка и тонкой кишки у больных с опухолевым поражениемголовки поджелудочной железы, которым по показаниям выполнялось радикальное оперативное вмешательство. Боль-ные были разделены на две подгруппы. В первой подгруппе 19 больным была выполнена панкреатогастродуоденальнаярезекция с антрум-резекцией в модификации Child, а во второй, 18 пациентам - пилоросохраняющая панкреатодуоде-нальная резекция – операция Traverso-Longmire. Для исследования моторно-эвакуаторной функции желудка, тонкойкишки и функционирования гепатобилиарной системы применялось одновременное внутривенное и пероральное введениедвух радиофармпрепаратов– технефита и бромезида с последующей регистрацией на двухдетекторной гамма-камере.Оценка состояния билиодигестивных анастомозов выполнялась с помощью внутривенно введенного препарата бромезид,содержащего 120 мегабеккерель (МБк) изотопа технеция Тс-99м, а для оценки гастроэнтероанастомоза применялась10% манная каша, меченая Тс-99м технефитом, с дозой 40 МБк Тс-99м. Исследование движения меченых соединений пожелчным путям и желудочно-кишечному тракту записывалась в память компьютера в течение 120 минут.Результаты и их обсуждение. В группе пациентов после радикального оперативного вмешательства, на предоперацион-ном этапе всем больным было выполнено исследование моторно-эвакуаторной функции верхнего отдела желудочно-ки-шечного тракта: у 21 больного отмечено незначительное замедление пассажа РФП из желудка (до 50 мин.), у 6 - периодполувыведения составил более 80 минут, при норме Т1/2 – 30 мин, что свидетельствовало о нарушении эвакуации пищииз желудка. У 10 пациентов патологии выявлено не было.У всех больных при выполнении второго исследования отмечено замедление выведения РФП из желудка. В первой под-группе период полувыведения РФП из желудка во время второго исследования составил 126,7 мин.±89 мин., что значи-тельно превысило норму (Т1/2 = 30 мин.). При этом замедление эвакуации было обусловлено не столько снижением мото-рики желудка, сколько энтеро-гастральным рефлюксом, преимущественно отмеченным с 90 минуты исследования. Вовремя третьего введения РФП Т1/2 желудка составила 75,3 мин.±17 мин.У пациентов из второй подгруппы, которым была выполнена ППДР, показатели периода полувыведения РФП из желудкабыли следующими: во время второй процедуры - 118,8±44 мин., во время третьей - 46,2±8 мин.Заключение. Применение радионуклеидного способа у больных с опухолевым поражением головки поджелудочной железыпозволяет проводить не только раннюю и комплексную диагностику моторно-эвакуаторной активности желудка, тон-кой кишки, желчных путей, но и более физиологично планировать тот или иной способ оперативного вмешательства.Применение на практике представленной диагностической методики демонстрирует объективные данные наличия убольных, перенесших ПГДР «ложного» гастростаза за счет энтеро-гастрального рефлюкса, а у пациентов, перенесшихППДР - «истинного» гастростаза, обусловленного либо анастомозитом, либо нарушением иннервации стенки выходногоотдела желудка после его мобилизации.Ключевые слова: Опухолевое поражение головки поджелудочной железы, радикальное оперативное вмешательство,гастроэнтероанастомоз, билиодигестивный анастомоз, панкреатогастродуоденальная резекция.

Bile Leak Leading to Lesser Sac Bile Collection Masquerading as Stomach in Hepatobiliary Scintigraphy

Images show normal tracer distribution in graft hepatocytes. Abnormal bile collection seen along the inferior margin of the liver which progressively collects at lesser sac (LS) displacing and compressing stomach (S) superolaterally (confirmed in Magnetic Resonance Imaging [MRI] coronal section). There is normal progression of tracer into intestinal loops. The first minute of dynamic image shows a large cold defect at the anatomical site of stomach which is in fact the unlabeled bile collection at LS (thin arrow) (Figure 1). As tracer progresses through biliary tree, radiolabelled bile starts collecting at the above site which is evident in the 15th minute image. The size and location of biliary collection remains unchanged even at 2 h delayed imaging. Normally stomach is not seen on an HBS. Commonest cause of stomach visualization on hepatobiliary scan is enterogastric bile reflux.1 If not careful, one may easily misinterpret and report the LS bile collection to be the stomach (by its size and placement) from an enterogastric reflux. The other teaching point is enterogastric reflux is best noticed in endless cine loop images as a jet of retrograde flow of tracer from duodenum into stomach in the first few minutes after injection which is the time taken for tracer transit through biliary radicles, common bile duct and hepatic outflow tract. Computed tomography (CT) and MR cholangiopancreatography (MRCP) images (Figures 2 and 3) confirm gross collection (12 × 10 cm) in the epigastrium adjacent to the cut surface of liver displacing and compressing the stomach laterally. Single photon emission computed tomography—computed tomography (SPECTCT) or MR correlation may be useful in identifying the displaced stomach. Bile leak collecting in lesser sac of peritoneum is important as it guides clinicians to decide on the site of placement of the drain tube in the abdomen. Biliary complications affect one in five liver transplant recipients.2 Incidence of biliary complications is higher (20–34%) after right-lobe live donor liver transplantation than from cadaveric transplants.3 Endoscopic retrograde cholangiopancreatography is the first-line treatment for biliary complications.4 HBS apart from identifying bile leaks is routinely used in postoperative patients for evaluating biliary-enteric anastomosis patency and in post-cholecystectomy patient with recurrent pain.1 Figure 1 HBS dynamic and static images. (A) Dynamic images (1 min/frame) show a large cold defect at the anatomical site of stomach (thin arrow). There is slow progressive collection of radiolabelled bile at the above site which is evident at 15th minute ... Figure 2 Transaxial CT image showing gross collection (12 × 10 cm) in the epigastrium adjacent to the cut surface of liver (thick arrow) displacing and compressing the stomach laterally (dotted arrow). LS: lesser sac. Figure 3 MRCP coronal images (A & B) show gross collection (12 × 10 cm) in the epigastrium adjacent to the cut surface of liver (thick arrow) displacing and compressing the stomach (S) laterally (thin arrow). ...

Classification schema of symptomatic enterogastric reflux utilizing sincalide augmentation on hepatobiliary scintigraphy.

Enterogastric reflux (EGR) is the reflux of duodenal contents into the stomach. Hepatobiliary scintigraphy provides physiologic assessment of the biliary system and was used to test the hypothesis that presence and timing of EGR may be associated with infusion of sincalide, a surrogate of endogenous cholecystokinin. One hundred fifty-seven hepatobiliary scintigraphy studies were retrospectively reviewed. Data included EGR incidence on initial reports, incidence after masked second reads, and time of EGR onset in relation to sincalide infusion. EGR cases were then classified according to onset on pre-, post-, or both presincalide and postsincalide imaging. Time of EGR onset at 19-24 minutes after start of a 15-min sincalide infusion differed significantly from normal (p<0.0001). EGR was initially reported in 14 of 157 cases (8.9%) but found in 38 of 157 cases on masked second reads (24.2%), corresponding to a 15.3% discrepancy rate. The temporal association of EGR onset with sincalide infusion may identify patients with EGR mimicking chronic cholecystitis or biliary dyskinesia. A novel classification schema was therefore developed as a framework for future research, utilizing EGR onset in relation to pre-, post-, or both presincalide and postsincalide imaging as a hypothetical biomarker of clinically significant EGR.

What is the best reconstruction method after distal gastrectomy for gastric cancer?

We performed this prospective randomized study to evaluate what is the best reconstruction method after distal gastrectomy for gastric cancer. One hundred fifty-nine patients who underwent laparoscopy-assisted or open gastrectomy for gastric cancer were analyzed from March 2006 to August 2007. Billroth I (B-I) anastomosis, Billroth II (B-II) with Braun anastomosis, and Roux-en-Y (R-Y) anastomosis were applied randomly. Additionally, the patients were divided into two groups based on treatment type: laparoscopic and open operation. Endoscopy and hepatobiliary scans were performed to investigate gastric stasis and enterogastric reflux. The Gastrointestinal Quality of Life Index (GIQLI) was used to evaluate postoperative quality of life, and the hematologic test was used to assess nutritional aspect. Endoscopy revealed that reflux after the R-Y anastomosis procedure was significantly less frequent than after the other anastomosis types at 12 months. Comparison of the GIQLI and the nutritional parameters between the reconstruction types revealed that there were no differences, but a significantly higher GIQLI score was observed in the laparoscopic group immediately following the procedure (P = 0.042). R-Y anastomosis is superior to B-I and B-II with Braun anastomosis in terms of frequency of bile reflux, despite the fact that there is no difference in the postoperative quality-of-life index and nutritional status between reconstructive procedures. The laparoscopic approach is the better option than open surgery in terms of QOL in the immediate postoperative period.

Magenstumpfkarzinom – Herausforderung der Onkochirurgie

Gastric stump carcinoma after gastric surgery for benign disease is now widely recognized as a distinct clinical entity. An electronic literature search was performed in the MEDLINE database to identify relevant studies concerning epidemiology, prognosis, treatment, aetiology and pathology of gastric stump carcinoma. The references reported in these studies were used to complete the literature search. It can be assumed that approximately 10 % of patients who had undergone a distal gastric resection for benign disease will develop a carcinoma in the gastric remnant about 15 to 20 years after the primary procedure. The incidence is reported to be higher in males and following Billroth II resection. The site of tumour growth is predominantly in the anastomotic area, but may occur anywhere in the stump. Enterogastric reflux, achlorhydria, bacterial overgrowth, and genetic factors appear to be the major factors involved in the aetiopathogenesis of the gastric stump cancer. Unfortunately, a significant proportion of patients presents with synchronous metastases. Clinical symptoms are mainly attributed to locally advanced tumour growth. Surgical therapy comprises total removal of the gastric remnant and the jejunal segment including modified lymphadenectomy (D2 lymphadenectomy and jejunal mesentery). Surveillance of patients with endoscopy and multiple biopsies should be initiated from the tenth postoperative year and may provide the means to diagnose tumours at an early stage.

Pancreatoduodenectomy with Subtotal Stomach-Preserving and Uncut Roux Reconstruction

Background/Purpose: Pylorus-preserving pancreatoduodenectomy (PD) has become the therapy of choice for resectable tumors located in the head of the pancreas and periampullary region. In addition, a distal gastrectomy may still be required for tumors located in the dorsal part of the pancreatic head or when there is evidence of proximal duodenal invasion. This may lead to postoperative complications, including gastric dumping, marginal ulceration, and bile reflux gastritis. This study reports on the postoperative course following subtotal stomach-preserving PD with the uncut Roux reconstruction diverting biliary and pancreatic secretions from the gastric remnant. Methods: A technique combining subtotal stomach-preserving PD with the uncut Roux reconstruction was applied in 10 patients. The postoperative clinical follow-up data are reviewed, and clinical criteria of biliary gastric reflux and gastritis were evaluated. Results: The postoperative course was uneventful in 4 patients and complicated in 6 patients. Delayed gastric emptying occurred in 3 patients. No deaths occurred in the postoperative period. One patient suffered from occasional nausea with abdominal discomfort for which endoscopy and cholescintigraphy were performed. Endoscopy confirmed complete occlusion of the afferent jejunal limb and showed marginal ulceration within the gastrojejunal anastomosis. Cholescintigraphy showed signs of enterogastric reflux. The check-up endoscopy following typical antisecretory therapy revealed complete ulcer healing. Four patients died of tumor recurrence 6, 7, 8, and 12 months following surgery. Conclusion: This pilot study suggests that the uncut Roux reconstruction may represent a good alternative to gastrointestinal reconstruction following PD. Further studies including the determination of intragastric bile acid concentration and radionuclide isotope scanning in a larger number of patients are warranted.

Long-Term Results of the Cut-Closed-Reconnected Roux Loop for Enterogastric Reflux

Background: The aim of this study was to present the long-term results of the cut-closed-reconnected (CCR)-Roux procedure for reflux gastritis. Methods: A retrospective analysis was performed on 14 patients with proven reflux gastritis and/or esophagitis who were treated at our institution with a CCR-Roux procedure between 1992 and 1997. Results: The closure of the afferent loop in the CCR-Roux procedure is effective and permanent. The CCR-Roux patients did not need a rest gastrectomy. No signs of Roux stasis syndrome were seen. There was a consistent weight gain at 2 and 5 years of follow-up. These results permit a comparison with those of the Roux-Y procedure and other alternative procedures as well. Conclusion: In the long run, the CCR-Roux procedure is effective in the treatment of reflux gastritis.

Gastric reddish streaks in the intact stomach: Endoscopic feature of reactive gastropathy

The pathogenesis of reddish streaks in the intact stomach is unclear. Sixty-three functional dyspeptic patients with gastric reddish streaks were recruited for the study. Fifty-five patients (group I) had only reddish streaks while nine patients (group II) had additional lesions such as reddish patches or spots randomly scattered throughout the stomach. Updated Sydney system and parameters of reactive gastropathy were used to score the biopsy specimens from reddish streaks separately. Helicobacter pylori infection rate was found to be markedly lower in group I than group II patients (13% vs 89%, P < 0.001). H. pylori-infected patients had higher scores for acute and chronic inflammation (P < 0.001) and foveolar hyperplasia (P < 0.005) than non-infected patients, while other parameters for gastritis and gastropathy were similar between infected and non-infected patients. In H. pylori-non-infected patients all biopsy specimens had at least one histological feature of reactive gastropathy. Bile reflux was observed in 54% of patients (34/63). Only 7.9% used non-steroidal anti-inflammatory drugs and 4.9% drank alcohol. The present data indicate that the fundamental histological features of gastric reddish streaks are reactive gastropathy with low H. pylori infection, and are probably enterogastric reflux related in etiology. Coincidental H. pylori infection increased acute and chronic inflammatory cell infiltration, and enhanced the grade of foveolar hyperplasia.

Intrathoracic Gastric Activity of Tc-99m Sestamibi in a Patient With Gastric Pull-Up for Esophageal Cancer

A 69-year-old man with remote gastric pull-up was evaluated with a 2-day stress-rest dypiridamole Tc-99m sestamibi myocardial perfusion imaging, where significant tracer uptake was noted in the posterior mediastinum related to enterogastric reflux of sestamibi. These ancillary findings were suggestive of a noncardiac etiology of the patient's atypical chest pain. This case highlights the value of examining the raw projection images for incidental findings that may be present during myocardial perfusion imaging.

Chemoprevention by celecoxib in reflux-induced gastric adenocarcinoma in Wistar rats that underwent gastrojejunostomy

To evaluate chemoprevention by celecoxib in cases of reflux-induced gastric adenocarcinoma, in Wistar rats that underwent gastrojejunostomy. Sixty male Wistar rats of average age three months underwent surgery and were distributed into three groups: group 1, exploratory laparotomy; group 2, gastrojejunostomy; and group 3, gastrojejunostomy and daily celecoxib administration. After 53 weeks, the animals were sacrificed. Changes in the mucosa of the gastric body of group 1 and in the gastrojejunal anastomosis of groups 2 and 3, observed in histopathological and immunohistochemical examinations, were compared. All statistical analyses were performed using Epi-Info, version 3.4.3. Comparison between groups 2 and 3 relative to the presence of adenocarcinoma showed a statistically significant difference (p=0.0023). Analysis of the association between groups 2 and 3 relative to COX-2 expression also showed a statistically significant difference (p=0.0018). Celecoxib had an inhibiting effect on gastric carcinogenesis induced by enterogastric reflux in an animal model.

The effects of Roux-en-Y limb length on gastric emptying and enterogastric reflux in rats

To assess the effects of Roux-en-Y jejunal limb length on gastric emptying and enterogastric reflux. Seventy male Wistar rats were submitted to antrectomy with Roux-en-Y reconstruction and then were divided into two groups of 35 animals. Group A, short limb (7.5 cm) and Group B, standard limb (15 cm). Group A and B were subdivided into five subgroups each in order to study enterogastric reflux at 30 and 60 minutes and to evaluate gastric emptying at 5, 10 and 15 minutes. In order to measure gastric emptying and enterogastric reflux, radiotracers 99m Tc-Phytate and 99m Tc-DISIDA were respectively used. For gastric emptying, the radiotracer concentration was lower in Group A than in Group B after five minutes. The enterogastric reflux was present, but there were no significant differences between enterogastric reflux indexes concerning both A and B Groups. A standard Roux limb, besides being unable to protect the stomach from the enterogastric reflux, may become a functional barrier for gastric emptying.

Pathogenic effects of primary duodenogastric reflux on gastric mucosa of children

Duodenogastric reflux (DGR) is a reverse flow of duodenal juice into stomach through pylorus composed of bile acid, pancreatic secretion, and intestinal secretion. The increased entero-gastric reflux results in mucosal injury that may relate not only to reflux gastritis but also esophagitis, gastric ulcers, carcinoma of stomach and esophagus. However, the exact mechanisms of gastric mucosal damage caused by DGR are still unknown. The objective of the present study is to investigate the pathogenic effect of primary DGR on gastric mucosa in children, and to explore the correlation of DGR with clinical symptoms, Hp infection and intragastric acidity. Totally 81 patients with upper gastrointestinal manifestations were enrolled and they were graded according to the symptom scores and underwent endoscopic, histological examinations and 24-hour intra-gastric bilirubin was monitored with Bilitec 2000. Of the 81 cases, 51 underwent the 24-hour intra-gastric pH monitoring by ambulatory pH recorder simultaneously. The total fraction time of bile reflux was considered as a marker to evaluate the severity of DGR. The total fraction time of bile reflux was compared between the patients with positive and negative results under endoscopy and histologically, respectively. The correlations of the total fraction time of bile reflux with clinical symptom score, Hp infection, intragastric acidity were analyzed respectively. The total fraction time of bile reflux in the patients with hyperemia and yellow stain gastric antral mucosa under endoscopy was significantly higher than that without those changes [17.1% (0.5% approximately 53.2%) vs. 6.5% (0 approximately 58.6%), Z = -1.980, P < 0.05; 19.8% (0.5% approximately 58.6%) vs. 8.8% (0 approximately 38.0%), Z = -2.956, P < 0.01 respectively]. Histologically, the cases with intestinal metaplasia had significantly higher total fraction time of bile reflux than in the cases without intestinal metaplasia [29.0% (1.9% approximately 58.6%) vs. 14.3% (0 approximately 53.7%), Z = -2.026, P < 0.05], but no significant difference was found either between the cases with and without chronic inflammation (P > 0.05) or between the cases with and without active inflammation (P > 0.05). The severity of bile reflux was positively correlated with the score of abdominal distention (r = 0.258, P < 0.05), but no correlation with either the severity of intragastric acid (r = -0.124, P > 0.05), or Hp infection (r = 0.016, P > 0.05) was found. Primary DGR could cause gastric mucosal lesions manifested mainly as hyperemia and bile-stained gastric antral mucosa under endoscopy and the gastric antral intestinal metaplasia histologically in children. There was no significant correlation between DGR and gastric mucosal inflammatory infiltration. DGR had no relevance to Hp infection and intragastric acidity. We conclude that DGR is probably an independent etiological factor and might play a synergistic role in the pathogenesis of gastric mucosal lesions along with gastric acid and Hp infection.

Roux-en-Y Reconstruction after Distal Gastrectomy to Reduce Enterogastric Reflux and Helicobacter pylori Infection

Enterogastric reflux (EGR) is regarded as an unavoidable consequence of distal gastrectomy. We evaluated the efficacy of Roux-en-Y (RY) gastrojejunostomy and Braun enteroenterostomy (BEE) for preventing EGR. Between January 2002 and January 2005, 60 patients who underwent distal gastrectomy for gastric cancer or peptic ulcers were divided into RY, Billroth II reconstruction (BII) without or with BEE (BII+B) according to reconstructive method. After 12 months, EGR and mucosal alterations of the remnant stomach were evaluated using biliary scintigraphy, endoscopy, and histology. Scintigraphy showed fasting and postprandial EGR into the remnant stomach occurred in 5.3% and 21.1% of the RY group, 62.1% and 93.1% of the BII group, and 50.0% and 91.7% of the BII+B group, respectively. Endoscopy showed bile reflux occurred in 15.8% of the RY group, 75.9% of the BII group, and 83.3% of the BII+B group. In addition, the prevalence of Helicobacter pylori (HP) infection in the RY group was less than in the other groups (P < 0.02). Therefore, RY after distal gastrectomy was effective in reducing EGR and HP infection. BEE was ineffective in diverting bile flow away from the gastric remnant.